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Joint Commission International (JCI) announces the modification of Accreditation Participation Requirement 7, which specifies requirements for selection and use of quality measures for its accredited hospitals and academic medical centers.

Effective 1 July 2015, each accredited hospital and academic medical center is required to select and use quality measures as part of its quality program in order to comply with Accreditation Participation Requirement (APR.7). The original APR.7 in Joint Commission International Accreditation Standards for Hospitals, 5th Edition, as well as the Governance, Leadership, and Direction (GLD) standards GLD.11 and GLD.11.1, called for hospitals and academic medical centers to collect and submit data on measures selected from JCI’s International Library of Measures (ILOM) and to use data specifications provided by JCI.

For on-site surveys conducted on 1 July 2015 and later, selection and use of measures other than those from the ILOM as part of the organization’s quality improvement program will be considered acceptable proof of compliance with APR.7 for hospitals and academic medical centers.

Hospitals and academic medical centers may use JCI’s ILOM measures and tools or measures and tools developed by the following bodies:

• The hospital or academic medical center’s quality leadership

• A municipal, regional, or national health authority

• An internationally recognized health care quality organization, such as the Institute for Healthcare Improvement (IHI), the Organisation for Economic Co-operation and Development (OECD) Health Care Quality Indicators program, or the U.S.-based Agency for Healthcare Research and Quality (AHRQ)

At this time, JCI does not require data submission except for surveyor review of data during the on-site survey as evidence of an ongoing quality improvement program.

“We listened to our accredited organizations when they told us that they need to select and use measures that best address their most critical quality issues,” said Paul Chang, MD, Vice President, Accreditation, Standards, and Measurement, JCI. “In some cases, organizations were collecting data on specific measures for local or national oversight bodies and data on other separate measures for JCI compliance. Those processes were becoming onerous in some cases. We think this change gives our accredited hospitals and academic medical centers the flexibility to tailor their quality improvement efforts to their needs and those of their patient populations, while remaining in compliance with JCI requirements.”

Dr. Chang emphasized that quality measurement and data analysis remain essential components of JCI’s accreditation process and that the ILOM should still be among the tools in the data-collection arsenal of a hospital or academic medical center.

“Data measurement and analysis are cornerstones of the JCI accreditation process. They are linked directly or indirectly to nearly every one of our standards,” Dr. Chang said. “Ensuring organizations generate meaningful data and using those data to inform decisions that improve patient care and outcomes remain at the center of our mission.”